Purpose: The purpose of this study was to identify current individual practice of perianesthesia nurses regarding assessment and documentation of pain.
Design: Descriptive cross-sectional design using vignette technique.
Methods: Vignettes with questions available via electronic survey offered to attendees of the 2017 American Society of PeriAnesthesia Nurses National Conference.
Findings: Total of 1,680 perianesthesia nurses participated; 41.4% reported assessment of pain compared with 36.7% who reported documentation of pain assessment. The numeric (0 to 10) pain intensity score was the most commonly used assessment method. Only 16.4% assessed for and documented pain location, 14.4% assessed for and documented quality of pain.
Conclusions: Pain assessment should include intensity, location, quality, and functional impact. The gap between nurses' practices in assessment and documention of pain may be related to system barriers. Embedding evidence-based best practice within electronic health records may improve both. Prior literature, as well as our findings, indicate these trends (missed documentation and assessment) are more global than only perianesthesia nursing.
Keywords: nurse pain documentation; pain assessment; perianesthesia nursing practice.
Copyright © 2020 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.